Equity considerations in clinical practice guidelines for traumatic brain injury and the criminal justice system: A systematic review

Background Traumatic brain injury (TBI) is disproportionately prevalent among individuals who intersect or are involved with the criminal justice system (CJS). In the absence of appropriate care, TBI-related impairments, intersecting social determinants of health, and the lack of TBI awareness in CJS settings can lead to lengthened sentences, serious disciplinary charges, and recidivism. However, evidence suggests that most clinical practice guidelines (CPGs) overlook equity and consequently, the needs of disadvantaged groups. As such, this review addressed the research question “To what extent are (1) intersections with the CJS considered in CPGs for TBI, (2) TBI considered in CPGs for CJS, and (3) equity considered in CPGs for CJS?”. Methods and findings CPGs were identified from electronic databases (MEDLINE, Embase, CINAHL, PsycINFO), targeted websites, Google Search, and reference lists of identified CPGs on November 2021 and March 2023 (CPGs for TBI) and May 2022 and March 2023 (CPGs for CJS). Only CPGs for TBI or CPGs for CJS were included. We calculated the proportion of CPGs that included TBI- or CJS-specific content, conducted a qualitative content analysis to understand how evidence regarding TBI and the CJS was integrated in the CPGs, and utilised equity assessment tools to understand if and how equity was considered. Fifty-seven CPGs for TBI and 6 CPGs for CJS were included in this review. Fourteen CPGs for TBI included information relevant to the CJS, but only 1 made a concrete recommendation to consider legal implications during vocational evaluation in the forensic context. Two CPGs for CJS acknowledged the prevalence of TBI among individuals in prison and one specifically recommended considering TBI during health assessments. Both CPGs for TBI and CPGs for CJS provided evidence specific to a single facet of the CJS, predominantly in policing and corrections. The use of equity best practices and the involvement of disadvantaged groups in the development process were lacking among CPGs for CJS. We acknowledge limitations of the review, including that our searches were conducted in English language and thus, we may have missed other non-English language CPGs in this review. We further recognise that we are unable to comment on evidence that is not integrated in the CPGs, as we did not systematically search for research on individuals with TBI who intersect with the CJS, outside of CPGs. Conclusions Findings from this review provide the foundation to consider CJS involvement in CPGs for TBI and to advance equity in CPGs for CJS. Conducting research, including investigating the process of screening for TBI with individuals who intersect with all facets of the CJS, and utilizing equity assessment tools in guideline development are critical steps to enhance equity in healthcare for this disadvantaged group.


Full search strategies 8
Include the search strategies for each database and information source, copied and pasted exactly as run.

Limits and restrictions 9
Specify that no limits were used, or describe any limits or restrictions applied to a search (e.g., date or time period, language, study design) and provide justification for their use.

Search filters 10
Indicate whether published search filters were used (as originally designed or modified), and if so, cite the filter(s) used.

Prior work 11
Indicate when search strategies from other literature reviews were adapted or reused for a substantive part or all of the search, citing the previous review(s).

Peer review 14
Describe any search peer review process.

MANAGING RECORDS
Total Records 15 Document the total number of records identified from each database and other information sources.
PRISMA Flow-Chart (Figure 1) Deduplication 16 Describe the processes and any software used to deduplicate records from multiple database searches and other information sources.provide registration information including registration number.

Eligibility criteria 6
Specify study characteristics (e.g., PICOS, length of follow-up) and report characteristics (e.g., years considered, language, publication status) used as criteria for eligibility, giving rationale.
Describe the rationale for including particular study designs related to equity research questions.
N/A 6A Describe the rationale for including the outcomes -e.g.how these are relevant to reducing inequity.

Data items 11
List and define all variables for which data were sought (e.g., PICOS, funding sources) and any assumptions and simplifications made.
List and define data items related to equity, where such data were sought (e.g. using PROGRESS-Plus or other criteria, context).

14
Describe the methods of handling data and combining results of studies, if done, including measures of consistency (e.g., I 2 ) for each meta-analysis.
Describe methods of synthesizing findings on health inequities (e.g.presenting both relative and absolute differences between groups).

Study selection 17
Give numbers of studies screened, assessed for eligibility, and included in the review, with reasons for exclusions at each stage, ideally with a flow diagram.

Study characteristics
18 For each study, present characteristics for which data were extracted (e.g., study size, PICOS, follow-up period) and provide the citations.
Present the population characteristics that relate to the equity questions across the relevant PROGRESS-Plus or other factors of interest.

21
Present results of each meta-analysis done, including confidence intervals and measures of consistency.
Present the results of synthesizing findings on inequities (see 14). Results

Table B : PRISMA Equity Checklist Checklist of Items for Reporting Equity-Focused Systematic Reviews Section Item Standard PRISMA Item Extension for Equity-Focused Reviews Pg # Title Title
N/A3AProvide the logic model/analytical framework, if done, to show the pathways through which the intervention is assumed to affect health equity and how it was developed.N/A Objectives 4 Provide an explicit statement of questions being addressed with reference to participants, interventions, comparisons, outcomes, and study design (PICOS).Describe how disadvantage was defined if used as criterion in the review (e.g. for selecting studies, conducting analyses or judging applicability).5 Indicate if a review protocol exists, if and where it can be accessed (e.g., Web address), and, if available, Methods (Paragraph 1)

Table 3
Conclusions26 Provide a general interpretation of the results in the context of other evidence, and implications for future research.Present extent and limits of applicability to disadvantaged populations of interest and describe the evidence and logic underlying those judgments.